Assessment Flashcards

1
Q

S3

A

Aka ventricular gallop
Not normally heard in people with normal heart sounds.
Can be present in healthy children and young adults
When heard in older adults, is often associated with moderate to severe heart failure
Is a soft, low pitched heart sound, when present considered to be “lub-DUB-da”
Often associated with abnormal filling pressures in the atria secondary to heart failure

page 341

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2
Q

Romberg test

A

Measures your sense of balance

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3
Q

Ptosis

A

Droopy eyelid

Can be just a little or can droop so much that it covers the pupil

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4
Q

Stridor

A

Brassy crowing sound often heard without a stethoscope
Caused by narrowing, swelling or obstruction of the upper airway and may indicate the pt has an airway obstruction in the neck or upper part of the chest

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5
Q

Tricuspid valve

A

Right atrioventricular valve.

Separates the atrium and ventricle on the right side of the heart.

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6
Q

Hearing Acuity

A

How well/clearly a pt can hear

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7
Q

Tinnitus

A

Ringing in the ears

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8
Q

Orthostatic vital signs

A

aka Tilt test
Measures fluid loss/dehydration
Measures BP and pulse rate for changes in supine, sitting and standing position

Considered positive when the pt’s systolic blood pressure decreases up to 20 mmHg, diastolic pressure increases more than 10 mmHg (a narrowing pulse pressure) and pulse rate increases by 20 beats
Take vitals at 1 min intervals between moving a pt to a new position.
Make sure not to take vitals right after moving the pt. You need to wait 2-3 minutes for the pt to be in the new position at least.

page 571

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9
Q

Acuity

A
Sudden onset
Critical 
Acuit MI
Acuit illness
Acuit episode
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10
Q

Confabulation

A

The creation of false memories

Person have no recognition that the information being relayed is fabricated

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11
Q

Going from pounds to kilograms

A

Number deviled by 2 minus 10%

150 divided by 2 minus 10%
180 deviled by 2 minus 10%

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12
Q

Rhonchi

A

aka Congested breath sounds
Lower pitch and a rattling quality
May indicate the presence of mucus in the lungs

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13
Q

PERRLA

A

Pupils

Equal

Round

Reactive to

Light and

Accommodations

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14
Q

S4

A

Aka atrial gallop
Not normally heard. If heard, almost always abnormal.
Medium pitched heart sound that occurs immediately before the normal S1 sound (like a flam). “bla-lub-DUB”
If present represents either decreased stretching (compliance) of the left ventricle or increased pressure in the atria.

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15
Q

Babinski reflex

A

Positive (abnormal) younger than 2 - when pt toes curl down

Negative (normal) under 2 - pt pulls away

Positive (abnormal) 2 and older when a pt’s toe(s) flex up from stimulation on the bottom of the foot

Negitive (normal) circumstances the toe(s) flex down if older than 2

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16
Q

Murmur

A

An abnormal whooshing sound heard over the heart that indicates turbulent (unsteady, violently) blood flow through the heart valves.

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17
Q

Orthopnea

A

 Positional dyspnea

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18
Q

Clubbing

A

Chronic respitory disease

Chronic hypoxia

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19
Q

S2

A

Is the second heart sound described as “DUB”.
Occurs near the end of ventricular contraction (systole) when the pulmonary and aortic valves close

page 340-341

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20
Q

Differential diagnoses

A

A list of possible conditions or diseases that could be causing the symptoms. `

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21
Q

Wheezing

A

Suggests lower airway obstruction
Is a high-pitched whistling sound that is most prominent on expiration but can be heard on inspiration in sicker pts

If only present unilateral suspect aspiration of foreign body or infection
If present bilateral suspect asthma

page 565

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22
Q

COASTMAP

A
C - Consciousness
O - Orientation
A - Activity
S - Speech
T - Thought
M - Memory
A - Affect (mood)
P - Perception

A detailed mental status exam

page 584

23
Q

Petechia

A

Pinpoint hemorrhage (kinda looks like freckles) - petechial hemorrhage – pinpoint red dot in the sclera of the eye

Pinpoint pink or red marks on skin, eyes

Petechial – characterized by small purple, nonblanching spots on the skin

24
Q

Diaphoresis

A

Excessive, abnormal sweating in relation to your environment and activity level

25
Q

The 5 P’s

A
Pain
Pallor - pale
Paresthesia - tingling, pins and needles
Paresis - weakness, partial paralysis
Pulselessness

Used to evaluate a limb for ischemia

page 581

26
Q

Urticaria

A

aka Hives

Is multiple small, raised areas on the skin that may be one of the warning signs of impending anaphylaxis

27
Q

Aortic valve

A

Left SL - semilunar- valve.

Separates the left ventricle and aorta

28
Q

Plantar reflex

A

Normal response to stroking the sole of the pt’s foot
toes curve downward

page 308

29
Q

Dyspnea

A

Shortness of breath

30
Q

Diplopia

A

Double vision

31
Q

Crackles

A

aka rales
fine crackles - sounds like rubbing hair between your fingers next to your ear
course crackles - sound more like small popping sounds and easier to hear
Indicates cardiac failure or infection, especially in young children

Crackles happen when oxygen/air passes through moisture in the bronchoalveolar system

32
Q

Battle sign

A

aka Retroauricular ecchymosis or Raccoon eyes.
Skull fracture

Bruising over the mastoid bone behind the ear,
which may indicate a basilar skull fracture

33
Q

Mitral valve

A

Left atrioventricular valve.

Separates the Atrium and ventricle on the left side

34
Q

Pulmonic valve

A

Right SL - semilunar - valve.

Separates the ventricle and the pulmonary arteries

35
Q

Rooting reflex

A

Occurs when something touches an infant’s cheek

the infant will instinctively turn his or her head toward
the touch

36
Q

Abducens

A
#6
Movement of eyeball in a lateral direction
37
Q

Minimum pedi systolic

A

70mmHg + (2 x age in years)

38
Q

ABCDE

A
Airway
Breathing
Circulation
Disability
Exposure
39
Q

Oculomotor

A
#3
Eye movement; elevation of upper eyelids; regulation of pupil size

page 309

40
Q

Bruit

A

Abnormal whooshing sound heard over a main blood vessel that indicates turbulent blood flow moving through a narrowed artery

41
Q

Mottled skin

A

Cardiovascular ‘embarrassment’ (as in shock), disseminated intravascular coagulopathy (DIC)
Patchy dark spots

42
Q

Olfactory

A

Reception and interpretation of smell

43
Q

Trochlear

A
#4
Movement of eyeball in a downward, inward direction
44
Q

Pleura friction rubs

A

Squeaking or grating sound

Occurs when the pleura linings rub together when they have lost their lubrication most common from inflammation

45
Q

Hyporesonance

A

aka Dullness

Indicates that the fields of the lung are full of blood

46
Q

Hemophilia

A

Genetic disorder usually inherited from the mother
With this people have significant decrease in one of their clotting factors
Pt’s bodies have a lot more difficulty stopping bleeding.

47
Q

Traumatic Fracture

A

occurs when abnormal forces are applied to normal bone structures.

48
Q

Moro reflex

A

Aka startle reflex

Occurs when an infant is caught off guard by something or someone

Infant opens arms wide, spreads the fingers and seems to grab at things

49
Q

S1

A

The first heart sound described as “lub”.
Occurs near the beginning of ventricular contraction (systole) when the tricuspid and mitral valves close.
Happens simultaneously

page 340-341

50
Q

Visual Acuity

A

Sharpness of vision. How well a pt can see. Measure by doing finger count and asking is this dark or light.

51
Q

Rhinorrhea

A

Runny nose

52
Q

DIC

A

Disseminated Intravascular Coagulopathy (DIC)

Condition in which small blood clots develop throughout the bloodstream. The increased clotting depletes the platelets and clotting factors needed to control bleeding, causing excessive bleeding.

53
Q

Pathologic Fracture

A

occurs when normal forces are applied to abnormal bone structures

54
Q

Reflection

A

Restating a word or phrase the pt told you so that you can confirm what you heard and get more detail from the patient